COLUMBIA — Coleen Kivlahan and Gus Kolilis had barely started working together when something sinister gave them both an eerie chill.
Kivlahan, a pediatrician leading a fight against child violence, and Kolilis, a retired St. Louis detective driven by a personal tragedy, were in a small conference room, piecing together the details of a child's death in rural Missouri.
It was 18 years ago, and one of their first cases in Missouri's new child fatality review system.
The father claimed the child fell out of his high chair and hit his head. But the autopsy and death scene led authorities to press him. He confessed that he had thrown the child against the kitchen wall in a rage.
That was tragic enough. But as Kivlahan and Kolilis pored through the family's housing and medical records, there was something worse: two other children had died in that family with the same head injuries.
"Then we knew," Kivlahan said. "We're on to something here."
They were already aware that in Missouri, parents and caregivers had been getting away with killing young children because of poor investigations and a failure of local coroners to perform autopsies. But now they realized that people had been getting away with it more than once.
"Multiple family homicides" was the first trend in child deaths revealed by Missouri's now nationally recognized Child Fatality Review Board system.
Started in that conference room in Jefferson City, the system can now be found in 49 states and is mandated by law in 44 of them.
The system has not only routed out foul play against children. Through data collection, it has identified child death trends and led to the creation of key prevention programs in such areas as shaken baby syndrome, sleep safety, teen suicide and even subjects as narrow as accidental drowning of babies in 5-gallon paint buckets.
Kivlahan, who later moved on to lead the state Department of Health, said this national reform would not have happened without Kolilis. He stayed on and worked for nearly two decades to bring justice and understanding to the children's deaths.
Kolilis was so open to sharing his knowledge that he was responsible for the rapid growth of child fatality review boards across the country, said Terri Covington, head of the National Resource Center on Child Death Review.
St. Louis County Medical Examiner Mary Case, a national expert on child abuse, called Kolilis "a rock."
"We have an excellent system in Missouri," she said. "But much of that excellence is because of him."
With a sheet cake and modest party, Kolilis, 67, retired this month as the head of what is now called the State Technical Assistance Team.
He said he is not ready to totally retire. He has set up a comfortable office in the basement of his newly built Columbia home with a portrait of his son in uniform overlooking his desk. He plans to continue his efforts to train police and others.
Kivlahan hired Kolilis on the spot in the lobby of the St. Louis Police Department headquarters in 1991. The police retiree said upfront he had little experience investigating child deaths. But then he told her he had a "personal issue" for wanting the job. His son, Robert, a state trooper, had died at 24 in the line of duty after being struck by a pickup. Kivlahan knew then she had found the right guy: someone who had felt the loss of a child.
"How Gus has been committed to this for that long, on that single issue, he is really," she paused, "a hero."
Given the popularity of "CSI" and other forensics TV shows, it seems hard to believe that just two decades ago, children with signs of abuse such as broken bones and deep bruises were being buried by undertakers who should have been performing autopsies in their roles as county coroners.
But it was happening in mostly rural areas of Missouri. The situation came to public light in 1991 through a series of Post-Dispatch articles, in which a Platte County coroner said, "Believe me, people get away with murder."
Suzanne McCune, who compiles state data on child deaths, said local officials often put more priority on the privacy of the families than on the pursuit of the truth.
Incensed, the General Assembly passed laws requiring every county to examine a child's death through a board consisting not only of police and coroners, but also doctors, teachers and social workers who may have known the child.
There were obstacles. Initially, no funding existed for mandatory autopsies, said Gary Stangler, then head of the Missouri Department of Social Services.
Case said many resented the law.
"The coroners didn't want to do this," she said. "This was work."
Yet Kolilis was "a monomaniac" about the job, Stangler said. Within a year, every county in the state had established a board.
Kolilis' wife, Sally, said her husband was on the road seven days a week in those early years, often driving in the middle of the night to remote corners of Missouri to investigate about 100 child fatalities a year. With his serious but affable manner, Kolilis won over coroners and police by offering to help unlock the truth.
Kolilis said most did not know what questions to ask and where to look, such as in the refrigerator to see if parents had been feeding their children. Local officials often were not aware that 90 percent of child murders are committed by parents or caregivers.
The state now has a technical assistance team of 10, and investigators are cued into such things as medical neglect and Munchausen syndrome by proxy, in which a caregiver secretly harms a child to gain sympathy and attention. The team is now considered a national leader in sexual assault investigations and using computer and cell phone forensics to combat child pornography.
Kolilis said the state had an election turnover of 39 sheriffs this year as well as an influx of new coroners. They all will require training, he said.
And despite great progress in deterrence, Kolilis said child abuse still rages behind closed doors.
"There are still children who fall through the cracks," he said.